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Provider Enrollment & Credentialing Specialist II, DentaQuest (Remote)

Sun Life Financial

Sun Life Financial

Administration
United States · Remote
Posted on Monday, September 18, 2023

You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You'll work with dynamic colleagues - experts in their fields - who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you'll have new and exciting opportunities to make life brighter for our Clients - who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.

DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.


Job Description:

Location: We support US virtual working arrangements in the contiguous 48 states.

At Sun Life, we look for optimistic people who want to make life brighter for our Clients. We understand the value of diverse cultures, perspectives, and identities, and want you to bring your full and authentic self to work. Every day, you’ll be empowered and challenged by working with dynamic colleagues to find new and innovative ways to make Sun Life the best benefits company in America.

The opportunity:

The Provider Enrollment and Credentialing Specialist II reviews all aspects of the Initial/ Re-Apply Credentialing, Re-credentialing, privileging and overseeing the onboarding process for all incoming providers. Primary duties include verifying all the credentialing criteria for practitioners that have applied to the network, including follow up with practitioners as needed to obtain information.

How you will contribute:

  • Verify potential and existing provider’s licensure, NPI, insurance, CDS, DEA certificate, education, hospital privileges, board certification.
  • Review National Practitioners Data Bank for adverse charges pending or filed against Provider.
  • Review federal and/ or state OIG and SAM report for exclusion from the Medicaid or Medicare program.
  • Review state Medicare OPT Out report for exclusion from the Medicare program.
  • Monitors and reports provider complaints and utilization management reports.
  • Assist with scheduling site reviews.
  • Enroll the provider into payment system – Windward.
  • Enter all provider information into credentialing database – Cactus.
  • Maintain the integrity of the provider information in Windward and Cactus.
  • Assist with processing provider approvals.
  • Ensures credentialing file is in order with any issues flagged for committee.
  • Meet required turnaround time and accuracy rate.
  • Assist with other duties as assigned.
  • Assist management in the implementation of department process improvements.
  • Assist with the ongoing NCQA certification activities.
  • Represent DentaQuest in a professional manner at all times while communicating with internal and external requestors.
  • Maintains confidentiality of the credentialing information.
  • Assist with running monthly and quarterly reports.
  • Ability to accurately and timely resolve credentialing issues presented by external or internal customers.
  • Collaborate with the team to identify opportunities for improvement both within the department and interdepartmental.
  • Assist with resolution of provider issues.
  • Other duties as assigned.

What you will bring with you:

  • High School Diploma or equivalent; Associate degree or higher preferred
  • 2 years job related experience
  • Knowledge of credentialing criteria, NCQA, CMS and or Managed Care requirements and processes.
  • Ability to work without supervision and provide assistance to other team members.
  • Excellent oral and written communication skills.
  • Knowledgeable in the use of department software (Credentialing and Enrollment Systems, Word, Excel, Outlook, Work Flow Software, Time Tracking Systems).
  • Ability to learn new software programs quickly.
  • Systematic, detail oriented and process driven.
  • Ability to navigate websites needed for credentialing purposes.
  • Excellent analytical ability.
  • Ability to adapt to a constantly changing environment.
  • Ability to prioritize and organize multiple tasks.
  • Ability to remain organized with multiple interruptions.
  • Excellent customer service and problem resolution skills.
  • Ability to with minimal guidance, complete assigned projects/tasks.
  • Ability to use good judgment and make quick decisions.
  • Ability to work in excess of 40 hours in a week.
  • Demonstrates self-motivation by taking the initiative to learn, take on additional responsibilities and make process improvement recommendations.
  • Experience with effectively communicating with Dentists or dental care professionals.
  • Required to attend additional training as requested/deemed necessary.
  • Knowledge of Dental terminology preferred.
  • Two to Five years of related professional work experience preferred.
  • Previous credentialing experience preferred

Do you see yourself in this role even if you haven’t checked all the boxes above? We welcome all talented candidates and are committed to a culture that represents diversity in all forms. If you think you might thrive in this setting, we would love to hear from you.

Not ready to apply yet but want to stay in touch? Join our talent community (https://pages.beamery.com/sunlifecareers/page/join-us-canada ) to stay connected until the time is right for you!

Life is brighter when you work at Sun Life

  • Excellent benefits and wellness programs to support the three pillars of your well-being – mental, physical and financial – including generous vacation and sick time, market-leading paid family, parental and adoption leave, a partially-paid sabbatical program, medical plans, company paid life and AD&D insurance as well as disability programs and more
  • Retirement and Stock Purchase programs to help build and enhance your future financial security including a 401(k) plan with an employer-paid match as well as an employer-funded retirement account
  • A flexible work environment with a friendly, caring, collaborative and inclusive culture
  • Great Place to Work® Certified in Canada and the U.S.
  • Named as a “Top 10” employer by the Boston Globe's “Top Places to Work” two years running

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

If you are a California resident, the salary range for this position is:

  • Southern region: $49,700 - 67,100 annually
  • Central region: $52,400 - 70,700 annually
  • Northern region: $56,000 - 75,600 annually

If you are a Colorado resident, the salary range for this position is $47,500 - 64,100 annually.
If you are a New York resident, the salary range for this position is $56,000 - 75,600annually.
If you are Washington resident, the salary range for this position is $52,400 - 70,700 annually.

We consider various factors in determining actual pay including your skills, qualifications, and experience. In addition to salary, this position is eligible for incentive awards based on individual and business performance as well as a broad range of competitive benefits.

Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter -for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career. Visit us at www.sunlife.com/us to learn more.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

At Sun Life we strive to create a flexible work environment where our employees are empowered to do their best work. Several flexible work options are available and can be discussed throughout the selection process depending on the role requirements and individual needs.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

Job Category:

Customer Service / Operations

Posting End Date:

24/12/2023

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran